Substituting Addictions – by Jeanene Swanson

Substituting Addictions

Many people will substitute one addiction for another during or after the recovery process from their original addiction. Are these people destined to become addicts for life, battling a never-ending cycle of recovery and relapse?

It is commonly believed that once you’ve had one addiction, you’re at greater risk of developing another. The concept of an “addictive personality” has been around for decades—and, it might shore up the “once an addict, always an addict” ideology of 12-step programs. Indeed, many people will substitute one addiction for another during or after the recovery process from their original addiction. Are these people destined to become addicts for life, so to speak, battling a never-ending cycle of recovery and relapse?

Not necessarily. “Most quality treatment programs teach about the likelihood of picking up another detrimental addiction [or behavior] after receiving treatment for one disorder, and most people in recovery know that they are susceptible to other addictions,” Dr. Deni Carise, Chief Clinical Advisor at Sierra Tucson treatment facility in Arizona, says. “Almost everyone in recovery from a substance use disorder knows that they need to give significant thought and be very careful if they decide to engage in behaviors that are known to have addictive potential.”

In fact, a recent paper published by researchers at Columbia University and the New York State Psychiatric Institute showed that addicts who remitted from an addiction were less likely to acquire a new one. So, what’s up? Should we be worried about substitute addictions—especially if they’re not necessarily harming us?

What is a substitute addiction?

Everyone who’s battled an addiction understands the concept: You go from smoking to eating; from drinking to shopping; from sex to chocolate to working. You’re substituting one addiction for another in an attempt to compensate for a perceived “lack”—emotionally or psychologically.

It’s important to distinguish addictions that occur at the same time—co-occurring—and substitute addictions. In a paper co-authored by Dr. Steven Sussman, a professor of preventive medicine and psychology at the University of Southern California, he categorized 11 “relatively common behaviors” as addictions—tobacco use, alcohol use, illicit drug use, binge-eating, gambling, Internet use, love, sex, exercise, work, and shopping—and then reviewed 83 studies, each with over 500 subjects, to see which behaviors were most prevalent over a 12-month period. They found that 23% of people had one or more addictions—or, co-occurring addictions. Interestingly, a whopping 47% of all US adults had at least one.

Two other general types of addicts, according to the same study, are people who have substitute addictions, “that is, where one addiction takes the place of a previously terminated addictive behavior in order to serve the same functions,” and people who only have one addiction in their lifetimes.

Substitute addictions aim to serve the same purpose as the original. Dopamine plays a large role, as the same mesolimbic pathways are activated in all kinds of addictions, whether substance or behavioral. After getting sober, many people feel a lack of the neurotransmitter dopamine also known as anhedonia, or the inability to experience pleasure in positive life events. One solution to this, Sussman believes, is to “engage in so-called positive addictions that are likely to “jump start” experience of pleasure on a somewhat regular basis.” While these could also have negative effects, addictions like exercise, work, a hobby, reading, gaming, or movies would be at least less destructive than using or engaging in risky sex or gambling, for instance.

What are common substitutes?

There has not been a lot of research looking at substitute addictions. Of those, studies have shown that overeating is a common substitute addiction for drug abuse, particularly for drinkers. Additionally, some people use drugs after they recover from bulimia, and vice versa. In one study, dating back to 1993, the researchers found that up to 25% of alcoholics sampled who had at least one year of sobriety substituted eating desserts, smoking cigarettes, and working more for up to 36 months. A study from 2004 found that in patients being treated for alcohol dependence, 15% started smoking cigarettes for the first time. Use of anti-anxiety medications such as benzodiazepines is not the first option among many clinicians interviewed due to their addictive quality—and possibility of becoming just another substitute addiction.

Says Sierra Tucson’s Carise, “It’s fair to say that more than 65% of people who have received treatment at Sierra Tucson are having difficulties with more than one of the following: alcohol, drug or eating disorders, excessive gambling, impulse control, depression, and anxiety.”

Addictive personality, addiction syndrome

Essentially, not all addicts are the same and not all pathways to addiction are the same. There are overlapping factors that influence whether someone will become addicted to a drug or process—genetics and neurochemistry affect the tendency toward addiction, as well as environmental and social factors. “I think there are several different types of relatively stable features that predict addiction proneness, [for instance] sensation seeking, anhedonia, positive or negative urgency,” Sussman says. “I doubt there is one type of addictive ‘personality.’”

It appears that there are people who are more likely to become addicts than others. “There is no single set of characteristics that individuals who become addicted have, but there are some that are more common among people with addiction problems,” Carise says. These include “an unusual tolerance for risk-taking, impulsivity, high sensation seeking, extraversion, depression, problems with authority roles, and a feeling of social isolation.”

In fact, addictive personality might be better described as someone who suffers from an addiction syndrome. In a 2004 paper describing the concept, Harvard Medical School’s Dr. Howard Shaffer outlined the shared traits many addicts have in common, including genetic underpinnings, as well as increased rates of co-morbid anxiety, depression, and PTSD.

“It’s important to keep in mind that if an individual has these traits, they are not doomed to have addiction problems, but they are at higher risk,” Carise says.

Beware of sneaky substitute addictions

While some substitute addictions, like exercise, can be positive—healthy stepping-stones to full and lasting recovery—some need to be treated, or at least monitored, in and of themselves.

“In the case of cross addiction or substitute addiction, a recovering alcoholic, for example, may turn to food as a source of reward and pleasure,” says Columbia University’s Dr. Nicole Avena, a leading researcher on eating disorders. “This relationship with food could develop into a substitute addiction. In some ways, this may seem like a “safer” addiction to have, but it can still be damaging and very distressful to the person suffering.”

Recently, there has been a surge in bariatric surgeries. And, researchers are noting that once patients lose the weight, they end up with new addictions, like alcoholism, gambling addiction, or compulsive shopping. It’s not really surprising, considering that binge-eating disorder is most similar of all the eating disorders to food addiction. Food and drugs are hypothesized to affect the same pleasure and reward circuits of the brain.

“Bariatric surgery patients may use drugs—or engage in other highly-rewarding activities—as a replacement for a food addiction that dominated before the surgery,” Avena says. “Especially if the individual has a family history of substance abuse, he or she may be more likely to resort to drugs as a means of coping and obtaining the rewarding feeling normally sought for in food.”

While many addicts turn to 12-step programs for help getting sober, becoming addicted to your Higher Power is an actual—and potentially problematic—substitute addiction. Sussman writes in a recent paper that “prayer, meditation, early romantic love, and drug abuse may have in common activation of mesolimbic dopaminergic pathways of the brain and the generation of intense emotional states. In this sense, reliance on a Higher Power may operate as a substitute addiction, which replaces the psychobiological functions formerly served by drug use.”

Other work points to the perils of becoming addicted to religion itself. There can be “negative consequences of relying on religion or spirituality,” Sussman says, which treatment providers should be aware of. He writes that the addict in recovery “may maintain potentially magical thinking that the Higher Power will fix him or her without engaging in corrective action…and may try to use rituals of connection to a Higher Power as means to escape from painful feelings.”

Lasting recovery

Whether addiction will be treated as a syndrome instead of a particular disorder in the future, many agree that getting to the core of what drives your addictive tendencies is key to lasting recovery. Is being addicted to the 12 steps less harmful than using? It remains to be seen—it’s still a “fix” that may be preventing someone from taking a more proactive role in changing his or her own life.

“Right now, I think we need to educate our patients about the dangers, particularly in early recovery, of other addictions cropping up,” Carise says. Taking an active role in your recovery—learning how to identify triggers and manage the thoughts and feelings that are part of addictive thinking patterns—will go a long way toward preventing relapse or substitute addictions that do more harm than good.